Healthcare Provider Details

I. General information

NPI: 1154191435
Provider Name (Legal Business Name): MADISON RAE HURLBUT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: QUINNTON RAE HURLBUT

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date: 12/31/2024
Reactivation Date: 01/28/2025

III. Provider practice location address

4455 E 12TH AVE
DENVER CO
80220-2415
US

IV. Provider business mailing address

1300 N 17TH AVE
GREELEY CO
80631-9584
US

V. Phone/Fax

Practice location:
  • Phone: 303-504-7700
  • Fax:
Mailing address:
  • Phone: 970-347-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: